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Respiratory Dullness to percussion may indicate lung consolidation or pleural effusion. Wheezes may be due to pulmonary oedema (‘cardiac asthma’) or COPD in this man. Pulmonary crepitations/ crackles, particularly if bibasal, suggest pulmonary oedema. A pleural rub would be consistent with PE or pneumonia. Other systems Establish a baseline for higher cerebral function (Abbreviated Mental Test Score) and neurological state (Glasgow Coma Scale). Examine the patient’s abdomen. Is there acute urinary obstruction with a large tender bladder?

Treatment of rate or rhythm, although in each individual patient both the risks and benefits of anticoagulation need to be carefully considered. In haemodynamically stable patients where atrial fibrillation is known to be of recent onset (<48 hours) and not precipitated by intercurrent illness, the patient should undergo electrical cardioversion. If that fails, pharmacological cardioversion should be attempted. Amiodarone is both antiarrhythmic and rate limiting (see below for dosing regimen). 5 mg in divided doses over 24 hours), particularly in the presence of left ventricular dysfunction, and beta-blockers.

Is she cyanosed? If she is, she is nearly dead. Respiratory rate must be interpreted in the context of the whole patient: a normal respiratory rate is consistent with imminent death in the asthmatic who is becoming exhausted. Widespread wheezing indicates airways obstruction, but beware the asthmatic who has a silent chest on auscultation: the tidal volume may be reduced so much that insufficient flow is being generated to create a wheeze. Check for signs of an underlying pneumothorax and for pneumonic consolidation.

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